Hindawi

Contrast Media & Molecular Imaging

Volume 2022, Article ID 4716978, 8 pages
https://doi.org/10.1155/2022/4716978

Research Article
Effect of Different Reduction Intramedullary Nails on Spiral
Fracture of Middle and Lower Tibia

Yongxin Shi,1,2 Fuqin Li,3 Weiguo Liang ,1 and Jinshi Liu2

1
Department of Orthopedics, Guangzhou Red Cross Hospital, Medical College, Jinan University, Guangzhou 510220,
Guangdong, China
2
Department of Orthopedics, Univercity of Chinese Academy of Sciences Shenzhen Hospital (Guangming), Shenzhen, China
3
Department of Social Welfare Centre, Univercity of Chinese Academy of Sciences Shenzhen Hospital (Guangming), Shenzhen,
China

Correspondence should be addressed to Weiguo Liang; [email protected]

Received 22 February 2022; Revised 10 March 2022; Accepted 17 March 2022; Published 28 March 2022

Academic Editor: Yuvaraja Teekaraman

Copyright © 2022 Yongxin Shi et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective. To compare the efficacy of different reduction and intramedullary nailing in the treatment of spiral fracture of middle
and lower tibia. Method. A total of 96 patients with spiral fractures of middle and lower tibia treated with intramedullary nails were
retrospectively analyzed. The patients were divided into closed functional reduction group, open anatomical reduction group, and
closed anatomical reduction group according to different treatment methods. The operation time, intraoperative blood loss,
intraoperative fluoroscopy times, fracture healing time, fracture nonunion, wound complications, and healing conditions of the
three groups were compared. Results. The operation time and intraoperative fluoroscopy times of patients in the closed anatomical
reduction group were significantly increased compared with those in the closed functional reduction group, while the fracture
healing time was significantly reduced. However, patients in the open reduction group had significantly more intraoperative blood
loss than those in the closed reduction group. The mean follow-up duration of patients was 15.81 ± 3.25 months. Open anatomical
reduction was found to have a higher complication rate during follow-up. Specifically, a total of 3 cases recovered after 2 times of
surgical treatment. 6 cases showed a small gap at the fracture end which did not affect the function. Conclusion. In the treatment of
middle and lower spiral fracture of tibia, closed anatomical reduction and intramedullary nail internal fixation have shorter
fracture healing time, less blood loss, and fewer complications, which can act as the first surgical choice. However, open reduction
and intramedullary nailing have a high complication rate, which is not recommended.

1. Introduction medullary cavity in the middle and lower tibia, anatomical

reduction often cannot be performed during closed reduction
Middle and lower spiral fracture of tibia, a common type of of the fracture, so fracture healing time is prolonged. Therefore,
fracture in clinical practice, is mostly caused by high-energy it is necessary to find new effective treatments. Some scholars
injuries and rotational violence [1, 2], which has a high inci- have studied the clinical efficacy of limited open medial ana-
dence in young patients [3]. Studies have shown that tibial tomical plate internal fixation in the treatment of middle and
spiral fractures are often associated with posterior ankle lower spiral fracture of tibia and found that it has good efficacy
fractures [4] and proximal fibular fractures [5] and in severe and few complications [12]. Therefore, 96 cases of middle and
cases can lead to posttraumatic osteoarthritis and secondary lower tibial fractures treated with intramedullary nails were
postoperative displacement [6, 7]. However, the efficacy of retrospectively analyzed to compare the efficacy of closed
traditional methods such as superarticular external fixation and functional reduction group, closed reduction and intra-
ordinary compression plate is not ideal [8]. At present, the medullary nailing, and open reduction and intramedullary
effective treatment is closed reduction and intramedullary nail nailing, providing clinical data support for the effective
internal fixation [9–11]. However, because of the large treatment of middle and lower spiral fracture of tibia.
2 Contrast Media & Molecular Imaging

2. Materials and Methods appropriate diameter was inserted along the long axis of the
tibia to achieve functional reduction of the fracture. Ana-
2.1. General Information. A total of 96 patients with spiral tomical reduction was unable to be achieved. There was a
fracture of middle and lower tibia admitted to our hospital certain degree of separation at the end of the fracture, and
from August 2015 to June 2020 were collected. According to the separation was less than 2.0 mm. The limb length was
the different treatment methods, the patients were divided restored under C-arm fluoroscopy. After correcting the
into the following three groups: closed functional reduction rotation, 3-4 distal locking screws were inserted. After ap-
group (n � 31): anatomic reduction of the fracture is not propriate compression of the fracture end, another 2 locking
achieved and the separation of the fracture ends is less than screws were inserted, and then the wound was sutured.
2.0 mm; open anatomical reduction group (n � 29); and Open anatomical reduction group: longitudinal incision
closed anatomical reduction group (n � 36). An informed (length: 4.0 cm) was performed at the fracture end. After
consent form was obtained from all patients, and the study exposing the fracture end, fracture reduction under direct
was approved by the Ethics Committee of the University of vision was conducted. Reduction forceps were applied to fix
Chinese Academy of Sciences-Shenzhen Hospital (2021263). fracture ends. The periosteum was protected as much as
Inclusion criteria were as follows: ① unilateral closed possible during the operation. There was no need to strip the
fracture of tibia; X-ray or CT examination and other imaging periosteum of fracture end. Then, intramedullary nailing was
examinations confirmed the diagnosis of middle and lower implanted as in the closed functional reduction group.
spiral fracture of tibia, with or without fibular fractures; ② fresh Impaction of screw or Kirschner wire was inserted at
fracture without fracture-related treatment; ③ normal ambu- fracture end to increase stability.
lation before fracture; and ④ surgical procedures were con- Closed anatomical reduction group: previous surgical
sistent with intramedullary nailing. procedures were the same as the closed functional reduction
Exclusion criteria were as follows: ① patients with group. If anatomical reduction of the fracture was not
combined vascular nerve injury; ② patients with osteopo- achieved under fluoroscopy, the intramedullary nails were
rosis; ③ pathological fracture; ④ patients with fracture line withdrawn and the guide wire was retained in the medullary
involving articular surface; ⑤ multifragmentary fracture; cavity to rereduce. The blocking screw technique was
and ⑥ reported impairments that accelerate fracture healing adopted. Specifically, a guide wire was first inserted into the
such as combined traumatic brain injury. medullary cavity on the acute angle side formed by the
fracture line at the distal end of the fracture and the guide
wire. Then, the intramedullary nails were reimplanted. If the
2.2. Treatment Methods. After admission, all patients were
reduction was still poor, the second Kirschner wire on the
subjected to immobilization and detumescence treatment,
acute angle side formed by the fracture line at the proximal
external fixation with plaster, and traction immobilization of
end of the fracture and the guide wire was implanted as a
the posterior calcaneal tuberosity. Surgical contraindications
blocking screw. Until the fracture end was anatomically
were excluded according to the patient’s comprehensive
reduced (separation was less than 1.0 mm), the length of
condition. The surgery was performed approximately 7 days
limb was restored under C-arm fluoroscopy. After cor-
after the patient reached the peak of swelling.
recting the rotation, 3-4 distal locking screws were inserted.
Before the surgery, the patients were given prevention of
After appropriate compression of the fracture end, two
deep venous thrombosis treatment and guidance of toe
locking screws were inserted. After that, the wound was
movement, quadriceps spontaneous contraction, hip and
sutured.
back lifting, and other painless exercises. 30 minutes before
surgery, cephalosporin was applied for infection prophy-
laxis. General anesthesia with endotracheal intubation or
arachnoid anesthesia was applied. With the patients supine 2.3. Postoperative Treatment. Cephalosporin was continued
on the operating table, a pneumatic tourniquet was tied to to be applied for the prevention of infection within 24 hours
the heel of the thigh. after surgery. Early active, painless ankle joint functional
Closed functional reduction group: hip flexion was about exercise and quadriceps contraction exercise were con-
90°, knee flexion was 90°–100°, and median longitudinal ducted during postoperative anesthetic resuscitation. On the
anterior incision of patellar ligament was about 4.0 cm in second postoperative day, active lifting of lower limbs and
length. The patellar ligament was split longitudinally. The passive knee training were conducted. And meanwhile, the
inferior fat pad was pushed to expose the bevel from the patients were guided to sit up and practice ambulation on
anterior edge of tibial plateau to tibial tubercle. Positioning crutches at the start of treatment for prophylaxis of deep vein
needles were inserted in the middle point of the bevel. After thrombosis. About 2 weeks after the operation, the stitches
the C-arm fluoroscopy guide wire was in the appropriate were removed after wound healing. The time of partial
position, the incision was opened and the guide wire was weight-bearing and full weight-bearing of the limb after
inserted. Subsequently, after reduction of the fracture under operation was determined according to the patient’s re-
C-arm fluoroscopy, a guide wire was inserted through the examination. The degree of fracture healing was checked in
fracture end to the distal tibial medullary cavity. Then, combination with the result of X-ray, and then the patients
reaming was performed. Intramedullary nailing with an were guided to walk with weight-bearing.
Contrast Media & Molecular Imaging 3

2.4. Evaluation Indicators. The operation time, intra- supply at the fracture site. Debridement was applied to
operative blood loss, intraoperative fluoroscopy times, and debride until the fracture site bleeding was restored. Then,
fracture healing time were recorded and compared. the autologous cancellous bone was implanted, and a re-
construction plate was adopted to fix the fracture site and
then to increase the stability (Figure 2(e)). Re-examination
2.5. Follow-Up. All patients were followed up. All compli- was conducted at 12 months after the second surgery, and
cations during follow-up were recorded, such as nonunion, the result showed the fracture was healed (Figure 2(f )).
wound complications, and the presence of small gaps at the In the closed anatomical reduction group, a 29-year-old
fracture end after healing that did not affect the function. man fell and caused spiral fracture of lower tibia shaft and
combined lower fractures of the tibia and fibula
2.6. Statistical Analysis. All data were analyzed using SPSS (Figure 3(a)). Closed reduction was applied. Specifically,
22.0 statistical software. Measurement data that were con- reduction was conducted with poller screws and anatomic
sistent with normal distribution were expressed as mean- reduction of fracture was achieved (fracture
± standard deviation (SD), one-way analysis of variance was displacement <1.0 mm) (Figure 3(b)). The result of re-ex-
used for comparison between multiple groups, and t-test was amination at 3 months after the operation showed that the
used for comparison between two groups. Enumeration data fracture line disappeared (Figure 3(c)) and the patient could
were analyzed by the χ2 test. P > 0.05 was considered sta- walk with normal weight-bearing (Figure 3(d)). The result of
tistically significant. re-examination at 5 months after the operation showed that
the fracture line had completely disappeared and the patient
could walk normally (Figure 3(d)). All the above results
3. Results indicated that patients in the closed anatomical reduction
3.1. Comparison of Surgical Indicators among Three Groups. group had the shortest postoperative healing time, while
Among 96 patients, 69 males and 27 females were included patients who received open anatomical reduction still re-
(age: 20–55 years). The surgery-related indicators of the quired a second operation.
three groups were recorded. The results revealed that the
operation time and fluoroscopy times in the closed ana-
3.3. Comparison of Postoperative Complications among the
tomical reduction group were significantly longer and much
Three Groups. All patients were followed up. The longest
more than those in the closed functional reduction group,
follow-up time was 60 months, and the average time was
while the fracture healing time was reduced. However, the
15.81 ± 3.25 months. Postoperative complications in the three
intraoperative blood loss of patients in the open anatomical
groups were recorded. The results indicated that, in the open
reduction group was significantly more than that in the
anatomical reduction group, there were 3 patients with wound
closed anatomical reduction group (Table 1).
exudate, including 2 cases of Staphylococcus epidermidis in-
fection and 1 case of Staphylococcus aureus infection. In the
3.2. Comparison of Postoperative Healing among Three closed anatomical reduction group, there was 1 patient with
Groups. CTscan was performed in the three groups to observe tibial fracture end blocking the drainage from the screw hole.
the postoperative healing. In the closed functional reduction Three patients in the open anatomical reduction group had
group, a 28-year-old man fell and caused closed spiral fracture unhealed fracture with large gap at the fracture site. The limbs
of right lower tibia shaft and upper fibular fracture of patients might be affected, and the fracture might reoccur.
(Figure 1(a)). Closed reduction and internal fixation were After the second debridement and bone grafting at the fracture
utilized to achieve fracture reduction (fracture site, the fracture was healed (Table 2). All the above results
displacement <2.0 mm) (Figure 1(b)). Ten months after sur- revealed that the incidence of postoperative complications in
gery, a re-examination was performed, and the results of CT the open anatomical reduction group was higher than that in
showed the fracture line was still in the patient and the fracture the closed anatomical reduction group.
was still unhealed (Figure 1(c)). The results of re-examination
at 14 months after surgery showed that the fracture had healed 4. Discussion
and the patient had no pain when walking (Figure 1(d)).
In the open anatomical reduction group, a 35-year-old Middle and lower spiral fracture of tibia, a common type of
man fell and resulted in spiral fracture of left lower tibia shaft fracture in clinical practice, is more common in young patients
and upper fibular fracture (Figure 2(a)). Open reduction and [13]. Intramedullary nails or internal fixation plate was a major
internal fixation were applied. A poller screw was implanted method in treatment of middle and lower spiral fracture of tibia
to increase stability, and the fracture was reduced completely [14–16]. The application of internal fixation plate extends
(Figure 2(b)). Re-examination was conducted at 18 months healing time, delays the time of ambulation with weight-
after the operation, and the results showed that the fracture bearing, and affects blood supply of incision of fracture, thereby
was still not healed (Figure 2(c)). Thirty months after sur- causing high fracture nonunion rate, infection rate, and so on
gery, the fracture was still not healed (Figure 2(d)) and the [17]. At present, most surgeons prefer intramedullary nailing
patient felt pain after walking for more than 100 meters, [18–20]. However, the anatomy of middle and lower spiral
indicating fracture nonunion. An incision was made to fracture site of tibia is special. Specifically, enlargement of the
explore, finding large bone defects and inadequate blood medullary cavity at the distal end of the fracture leads to
4 Contrast Media & Molecular Imaging

Table 1: Comparison of surgical indicators among three groups.

Operation time Intraoperative blood loss Intraoperative fluoroscopy Fracture healing time
Group
(min) (ml) times (time) (week)
Closed functional reduction
101.35 ± 15.36 96.58 ± 19.81 12.20 ± 1.61 38.65 ± 12.36
group (n � 31)
Open anatomical reduction
98.51 ± 10.33 136.25 ± 10.68∗ 9.31 ± 1.20 39.15 ± 13.49
group (n � 29)
Closed anatomical reduction
132.58 ± 19.66# 98.28 ± 10.22 23.63 ± 2.99∗ # 12.61 ± 6.39∗ #
group (n � 36)
F value 8.615 23.25 58.22 45.36
P value 0.014 0.019 <0.001 <0.001
The data were expressed as mean ± SD. Compared with the closed functional reduction group, ∗p < 0.05; compared with the open anatomical reduction group,
# P < 0.05.

(a) (b)

(c) (d)

Figure 1: Preoperative and postoperative CT scans of one patient in the closed functional reduction group. Preoperative (a) and
postoperative (b) CT scan of the patient; CT scan of the patient at 10 months (c) and 14 months (d) after operation.

difficulty in reduction and fixation [21]. Unlike easy achieve- middle and lower spiral fracture of tibia. In this study, it was
ment of anatomical reduction in oblique fracture or transverse found that all patients in the closed anatomical reduction group
fracture, the spiral fracture can often only achieve functional achieved good healing with the shortest healing time on average.
reduction. Furthermore, the blood supply of the middle and Also, the patients recovered well without any complications or
lower tibia is single, so both fracture and surgical procedures are sequelae. However, in the closed functional reduction group, the
easy to destroy the blood supply of the site of the fracture, patient did not undergo open reduction and the fracture healing
thereby resulting in complications such as delayed fracture time was obviously prolonged. Nevertheless, all 31 patients had
healing and nonunion [22, 23]. We retrospectively summarized good fracture healing without sequelae or serious complica-
the treatment and healing of the fractures and found that the tions. In the open anatomical reduction group, three patients
degree of reduction of the fracture and whether the site of underwent a second operation and significant complications
fracture was incised were two key factors affecting fracture also occurred in healing patients. Because of less soft tissue
healing and efficacy. Good fracture reduction and blood supply coverage and special blood supply in the middle and lower tibia
protection at the fracture end can achieve perfect healing of and especially the worst blood supply on the medial surface of
Contrast Media & Molecular Imaging 5

(a) (b)

(c) (d)

(e) (f )

Figure 2: Preoperative and postoperative CT scans of a patient in the open anatomical reduction group. Preoperative (a) and postoperative
(b) CT scan of the patient; CT scan of the patient at 18 months (c) and 30 months (d) after operation; (e) the image of the patient who
received the second surgery; (f ) CT scan of the patient who received the second surgery at 12 months after operation.

the tibia, the periosteum supply becomes the main supple- suggested that the stimulation to the periosteum might be the
mentary source [24]. Also, open reduction, especially the use of cause of internal fixation failure and recurrent fractures.
reduction forceps, damages the periosteal blood supply [25, 26], The findings of closed anatomical reduction in this study
thereby causing the occurrence of nonunion. are shown as follows: ① anatomical reduction of the tibia
During this study, it was also found that although the was easily achieved in patients without fibula fracture; ② for
patients had good functional recovery in their limbs, the bone patients with tibiofibular fracture, preoperative use of cal-
strength was reduced to some extent and the risk of recurrent caneal tuberosity bone traction could help tibial fracture to
fracture was increased at a later stage. Besides, the large amount achieve anatomical reduction during surgery [28]; ③ ra-
of callus formed at the site of fracture end in patients was tional use of muscle relaxants could reduce the difficulty of
different from the callus formed during the healing of the reduction; and ④ the poller screw technique played a sig-
fracture. Healing of fractures relies on internal callus formation nificant role in anatomical reduction of middle and lower
[27]. The callus formed in this study belonged to external callus spiral fracture of tibia [29–31]. Specifically, after implan-
formation and did not participate in the process of creeping tation of the intramedullary nail, if the separation of the
substitution, so it had little use for the healing of fractures. Also, fracture site was found to be longer than 2.0 mm, the
the external callus did not appear in large numbers at the intramedullary nail was pulled out. Then, the Kirschner wire
fracture line, but at both ends of the fracture line, which was inserted through the medullary canal at the sharp angle
6 Contrast Media & Molecular Imaging

(a) (b)

(c) (d)

Figure 3: Preoperative and postoperative CT scans of a patient in the closed anatomical reduction group. Preoperative (a) and postoperative
(b) CT scan of the patient; CT scan of the patient at 3 months (c) and 5 months (d) after operation.

Table 2: Comparison of surgical complications among the three groups.

The incidence of
Nonunion Wound complications Small gap at fracture end
Group complications
(case) (case) (case)
(%)
Closed functional reduction group
0 0 0 0
(n � 31)
Open anatomical reduction group
3 3 6 41.38 (%)∗
(n � 29)
Closed anatomical reduction group
0 1 0 0.028 (%)#
(n � 36)
χ2 value — — — 92.92
P value — — — <0.001
Compared with the closed functional reduction group, ∗p < 0.05; compared with the open anatomical reduction group, # P < 0.05.

between the distal fracture and the guide wire, and the closed functional reduction can be applied. However, the use
intramedullary nail was reimplanted. If anatomical reduc- of open anatomical reduction should be reduced due to the
tion was still not achieved, a second Kirschner wire could be high incidence of nonunion.
inserted and an intramedullary nail was also reimplanted,
until the fracture was well reduced.
Data Availability
5. Conclusion The data used to support the findings of this study are
available from the corresponding author upon request.
To sum up, intramedullary nailing can offer good efficacy for
the treatment of middle and lower spiral fracture of tibia. Conflicts of Interest
Closed anatomical reduction can act as the first choice of
treatment. If anatomical reduction cannot be achieved, The authors declare that they have no conflicts of interest.
Contrast Media & Molecular Imaging 7

Authors’ Contributions fracture,” Journal of the College of Physicians and Surgeons--

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“Management of extra-articular fractures of the distal tibia:
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